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New concussion test

Baseline test will provide basis to measure injury in young players

Tuesday, February 29, 2000

By Brenden Sager, Post-Gazette Staff Writer

Simple tests that help evaluate the severity of concussions suffered by professional athletes may soon be available to youth sports to ensure children are not returned to competition too soon.

More than 60,000 high school athletes suffer concussions each year, according to Joseph C. Maroon, a neurosurgeon with UPMC Health System who developed the tests used by some professional teams.

Sixty-three percent of these injuries occur in high school football, but concussions also occur in basketball, hockey, wrestling and in growing numbers in boys' and girls' soccer.

Concussions -- known as mild traumatic brain injuries -- may involve a brief loss of consciousness and/or memory after an injury to the brain that doesn't cause obvious physical damage. People don't always lose consciousness, Maroon says, causing many people who have suffered concussions to be misdiagnosed.

And brain injuries suffered during a concussion typically don't show up on CT or magnetic resonance imaging scans.

Concussions need to heal on their own. If an athlete returns to play too soon and suffers a second or repeated concussions, he may experience lifelong impairments such as amnesia, disorientation and learning disabilities.

Maroon, with neuropsychologists and athletic trainers, has developed a series of quizzes and interviews that test an athlete's orientation, memory, vision, attention span, language, mental flexibility and coordination. Maroon says this is the best way to test for confusion and amnesia, and helps determine when an athlete is ready to return to competition.

The researchers' tests, called the "Steelers Battery," has been used to evaluate concussions in the National Football League and National Hockey League since 1997. They've also received grants from the National Collegiate Athletic Association to test college athletes.

Maroon's team now is developing an inexpensive computer test that can be given by computer to younger athletes by their coaches and trainers instead of by medical professionals. The program is being developed at the Henry Ford Health System in Detroit, which has tested high school athletes for two years.

Henry Ford expects to roll out the program nationally this fall to about 100 schools, said Mark R. Lovell, a neuropsychologist at Henry Ford. Upper St. Clair High School might be the local launch pad, primarily because its football coach, Jim Render, is one of Maroon's patients.

Under the program, if a high school athlete suffers a concussion, he'll answer questions provided in the computer program. These will be e-mailed by coaches and trainers to Henry Ford researchers, who will assess the results and make recommendations. Even schools in remote areas will be served.

The software also will allow researchers to collect more data to better understand this confusing condition.

"All indications are that this is something that's going to be a major advance," Maroon said.

When Maroon began studying concussions more than 20 years ago, definitions of this injury were so broad, they were of little use to coaches, trainers or even medical professionals.

Even now, coaches and trainers in some sports may simply ask a player who's banged his head if he still feels "foggy" in assessing whether he's ready to return to the game.

Many sports physicians rely on a grading system from the American Academy of Neurology to determine the severity of a concussion and when an athlete can return to play. In grade one there is no loss of consciousness and fewer than 15 minutes of symptoms, such as headache, dizziness or fogginess. In grade two, there is no loss of consciousness and more than 15 minutes of symptoms. In grade three, the player loses consciousness.

Under grade one, an athlete may return to contest if there are no symptoms or changes in mental status after 15 minutes. Players should be removed from the game and sit out at least a week for a grade two concussion, and the athlete should be sent to the hospital immediately for grade three.

Based on research, Maroon said being knocked out is becoming less important than the post-traumatic mental function. That's where his tests come in.

Administered to an athlete during preseason, the tests measure everything from memory to speech fluency to decision-making to how quickly they can retrieve words and talk.

If a player suffers a concussion, specialists retest him. They compare the results with the baseline to determine differences. Maroon said each mental function tested takes place in different areas of the brain. If an athlete has trouble with one of these functions after head trauma, doctors can more easily isolate the location of the brain injury -- without expensive scans or more invasive procedures.

When cognitive functions return to the baseline measure, the athlete can return to the field. If problems persist, doctors can recommend the athlete stop competing. The system also allows doctors to monitor progress of recovery or progressive damage.

The cumulative affects of concussions may last long beyond the initial injury. In analyzing data from the 1997 and 1998 college and professional football seasons, Michael Collins, a neuropsychologist at Henry Ford, found that players who suffered concussions were more likely to have learning disabilities than others.

In rare cases, concussions are fatal. Twenty-six deaths have been attributed to "second impact syndrome" -- or repeated concussions -- in the United States since 1984.

Maroon said several concussions can cause by structural damage to of individual brain cell membranes, disturbing osmosis, the process by which nutrients pass back and forth through the cell's semi-permeable membrane.

The brain cell "hypo-metabolizes" its available nutrients -- in effect, overheating like a car engine and breaking down. The cells may still be viable, but more susceptible to re-injury and death.

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